Documenting presence: A descriptive study of chaplain notes in the intensive care unit

Area of Science:

• Medical Sociology
• Healthcare Communication
• Spiritual Care in Medicine

Background:

• Hospital chaplains are increasingly expected to document patient care in medical records.
• Existing chaplain documentation practices exhibit significant variability across institutions and settings.
• Understanding the nature and interpretation of chaplain documentation is crucial for integrated patient care.

Purpose of the Study:

• To investigate and analyze the methods hospital chaplains use to document patient encounters in an intensive care unit (ICU).
• To identify emergent themes in chaplain documentation within the ICU setting.

Main Methods:

• Conducted a retrospective chart review of chaplain notes from adult ICUs over a six-month period.
• Employed qualitative textual analysis to code and identify themes in chaplains' free-text entries.

Main Results:

• Chaplain documentation frequently utilized "code language" (e.g., "compassionate presence") to summarize existing ministry interventions.
• Notes primarily described observations rather than offering clinical interpretations.
• Follow-up plans were often passive, relying on patient or family initiation, though some relational insights were noted.

Conclusions:

• The emphasis on evidence-based practice may encourage a reductionist, mechanical language in chaplain documentation, potentially obscuring patient narratives.
• There is a need to refine chaplain documentation to better communicate clinically relevant information and the unique value chaplains bring to the interdisciplinary care team.
• Further research should explore strategies to enhance the clarity and impact of chaplain documentation in acute care settings.